The Effects of Training on Inhaler Technique and Quality Of Life in Patients with COPD

Abstract

Objectives:

This experimental study was conducted to determine the effects of training on inhaler technique and quality of life in patients with chronic obstructive pulmonary disease (COPD).

Methods:

Among the patients who applied at the outpatient clinic of chest diseases between March 2009 and May 2010, a total of 69 with COPD who complied with the criteria of the study were recruited; of these, 34 subjects were put in the intervention group and 35 in the control group. The intervention group was educated on using an inhaler by verbal training, demonstration movie, and leaflet. A follow-up after 3 months was carried out in both groups.

Results:

Of the intervention group, 82.4% used the inhaler correctly; however, in the follow-up, all of the controls used it incorrectly (p<0.05). The number of attacks (p<0.001), emergency applications, and hospitalizations (p>0.05) of the intervention group was lower at the follow-up than in the control. Promotion in all areas of quality of life was determined in the intervention group (p<0.001).

Conclusion:

Consequently, a planned inhaler training given to the patients with COPD was found to decrease attack frequency and dyspnea, and improve quality of life.

Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease that is characterized by limited air flow not being completely irreversible. COPD is a leading cause of morbidity and mortality in countries of high, middle, and low income. COPD is estimated to become the third leading cause of death worldwide by 2020. The aims of medical treatment of COPD are providing bronchodilatation, suppressing inflammation, preventing attacks, enhancing quality of life, and decreasing mortality.^(1,2) Based on these purposes, inhalers are important parts of the therapy. Inhalers are frequently preferred due to their efficiency with low dosage, direct entry to the airway, and few systemic adverse effects compared with systemic therapy.⁽³⁾

Adequate therapeutic action in inhaler therapy is based on adequate distribution of the medicine to airways. Incorrect inhaler use leads to failure in controlling symptoms, increase in morbidity and mortality, and decrease in quality of life.^(4–7)

Incorrect inhaler technique rate was found to be 24–91% in several studies.^(4,8,9) Proper inhaler technique is not easy for every patient. Especially the elderly and children have difficulty in inhaler use.⁽¹⁰⁾ Therefore, a careful assessment and teaching of the correct inhaler technique are crucial in patient education. Correction and prevention of mistakes in inhaler medicine applications are possible with appropriate patient education held by health professionals.⁽¹¹⁾ Study results demonstrated that 11–25% of inhaler-using patients were not educated on inhaler usage by health professionals.^(12,13) Yet appropriate training could correct the mistakes about inhaler usage, decrease the symptoms of the disease, increase adherence to therapy, prevent attacks, and increase quality of life.^(14–17)

Studies on inhaler use in patients with COPD conducted in Turkey have investigated patients' inhaler-using situations and outcomes of training. However, the effects of inhaler-use training on quality of life and pulmonary functions were not mentioned widely.

The aim of health education is to teach the patient to live a healthy life, and thus to provide an effort for the patient in order to keep his/her health potential maximum.⁽¹⁸⁾

Hence, nurses have an important duty concerning the education of inhaler medication. When inhaler medicines are prescribed for inhaler-using patients, proper training should be given and repeated regularly for them.

Material and Methods

The study was held in the outpatient clinic of chest diseases in a university hospital. The research sample was composed of subjects with COPD who applied to the outpatient clinic of chest diseases between the dates of March 2009 and May 2010. During the study process, mostly male patients applied to the hospital due to a higher prevalence of male patients with COPD in Turkey. Patients with COPD who were regularly using inhalers were recruited to the study. The types of inhalers used by study participants were: metered dose inhaler (MDI), Turbuhaler, Aerolizer, HandiHaler, and Diskus. The majority of patients were using more than one inhaler.

Patients diagnosed at least 3 months with COPD in moderate and severe stages according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria were included. Also, patients who had been using the inhaler medication for at least 3 months and using it incorrectly were included in the study.

Patients who had serious visual, hearing, and communication problems and disorder of mental function, with mild and very severe stages of COPD and attack, with serious pulmonary or cardiological disease, malignancy, pulmonary infection, and who were using the inhaler with a correct technique (with a score of 10 on the inhaler checklist) were excluded from the study due to the possibility of having an influence on the results of the study. This experimental study was conducted to determine the effects of training on inhaler technique and quality of life in patients with COPD. By verbal training, demonstration, video player, and leaflet, patients with COPD in the intervention group were educated and, 3 months after the training, quality of life, condition of dyspnea, emergency application, attacks, and hospitalization were evaluated.

Patients in the control group were not educated but have been checked with the same indicators. Quality of life, condition of dyspnea, and attack improved 3 months later in the intervention group compared with the controls.

Sampling and sample size

The study sample was composed of 69 patients with COPD who had incorrect inhaler technique and were put into either the intervention group (n=34) or the control group (n=35) (Table 1). To provide randomization, the study was started with control group patients first and continued as interviewing with (1) intervention group patients for 1 day and (2) with control group patients for one other day. The sample was reached in 15 months. The power of the study was found to be 0.99 based on the scale of quality of life at a confidence interval of 0.05 by the SigmaStat program (version 3.5).

Table 1.

Participant Flow Through Trial

N=109 1st Interview
Intervention group Baseline n=54	Control group Baseline n=55
Refused (n=12)	Refused (n=14)
Died (n=2)	Died (n=1)
Could not be contacted (n=4)	Could not be contacted (n=2)
Subsequent cancer diagnosis (n=2)	Subsequent cancer diagnosis (n=3)
After 3 months n=34 (% 63)	After 3 months n=35 (% 64)
N=69 Follow-up

Patient training

Data were collected by a face-to-face interview between the hours of 8:30 AM and 12:00 PM on weekdays for 15 months by the researcher. Three months after the interview, patients were invited for the second one (follow-up). Intervention and control group patients were interviewed on separate days due to the probability of having an influence on the study results. Placebo inhalers were used for the patients in both groups to prevent them from taking a high dosage. Training took 15–20 min on average and was held in a separate room apart from the outpatient clinic in order not to interrupt the conversation.

With an inhaler checklist, patients in the intervention group were assessed on how they used their inhalers, and the scales and questionnaire were performed. By verbal presentation and demonstration, patients were educated on how they would use their inhalers, visual presentation by video player was done, and patients were asked to use their inhalers in the way they had been told according to the checklist. Improper applications were corrected by repeating until the patients used the inhalers correctly.

When the interview ended, a leaflet that was prepared by the researcher based on the literature was given to patients and they were asked to come to a second interview 3 months later. During the second interview (follow-up), inhaler use was evaluated and forms were performed again. Patients who were using the inhaler incorrectly were trained again.

Control patients with COPD were monitored similarly to the intervention group, but were given no training on inhaler use. In the follow-up, controls were assessed by the same forms, and when the study ended, they were given the same training as the intervention group.

Measurements

Data were collected by a questionnaire that included questions about sociodemographic characteristics, qualities related to disease, and a pulmonary function test. The Borg dyspnea scale, Medical Research Council Dyspnea Scale (MRC), St George respiratory questionnaire (SGRQ), and inhaler checklist were performed.

Sociodemographic and clinical characteristics

The questionnaire form consisted of 34 questions about sociodemographic characteristics such as age, gender, social assurance, educational status, drugs used, the stages and duration of disease, and results of a pulmonary function test.

Borg dyspnea scale

This scale was improved by Gunnar Borg in 1982 in order to identify the intensity of physical activity. The scale is often used especially for COPD cases in determining daily and weekly dyspnea changes. It is composed of 10 items describing severity of dyspnea based on its degree. The score 10 means dyspnea is at a high degree that has not been lived ever before by the individual.⁽¹⁹⁾

MRC dyspnea scale

MRC, improved by Fletcher et al. (1959),⁽²⁰⁾ is a categorical scale, which chooses an expression among five statements related to shortness of breath aimed at describing the best dyspnea level. Higher scores of MRC demonstrate that perception of shortness of breath is more severe.⁽²⁰⁾

SGRQ

The SGRQ is a scale of quality of life used in COPD and asthma. The validity and reliability study for Turkey of the scale, which was improved by Jones and colleagues,⁽²¹⁾ was held by Özkan et al.⁽²²⁾ In the present study, the pre–Cronbach alpha coefficient of SGRQ was 0.89, whereas the post–Cronbach alpha was 0.91. The SGRQ is a standardized self-administered airways disease–specific questionnaire divided into three subscales: symptoms (8 items), activity (16 items), and impacts (26 items). SGRQ scores were calculated using score calculation algorithms and missing data imputation (if total number of missing items was 10) recommended by its developer. For each subscale and for the overall questionnaire, scores range from zero (no impairment) to 100 (maximum impairment).⁽²¹⁾

Inhaler checklist

Based on the literature^(8,23,24) and expert view from the chest disease clinic, the checklist was prepared separately according to every inhaler type by the researcher. Inhaler technique was accepted as proper when every step controlled in the checklist was correct, and the technique was wrongly applied when one or more steps were incorrect. The inhaler-using skill checklist includes 10 steps. A score of incorrect application for every step was “0” and for correct application was “1.” Total score is between 0 and 10 (Table 2).

Table 2.

Inhaler Checklist Used in the Study

	Diskus	True	False
1.	Open the device (hold the horizontal)	1	0
2.	Slide the lever	1	0
3.	Keep head upright	1	0
4.	Exhale to residual volume	1	0
5.	Mouthpiece between teeth and lips	1	0
6.	Inhale forcefully and deeply	1	0
7.	Don't exhale, remove inhaler from mouth	1	0
8.	Hold breath for 10 sec	1	0
9.	Exhale away from mouthpiece	1	0
10.	Replace the cover	1	0
Total

	MDI	True	False
1.	Remove cap	1	0
2.	Shake the inhaler	1	0
3.	Hold inhaler upright	1	0
4.	Keep head upright	1	0
5.	Exhale to residual volume	1	0
6.	Mouthpiece between teeth and lips	1	0
7.	Inhale slowly and press canister	1	0
8.	Hold breath for 10 sec	1	0
9.	Exhale away from mouthpiece	1	0
10.	Replace the cover (wait a minimum of 20–30 sec before second inhalation)	1	0
Total

	Turbuhaler	True	False
1.	Twist and remove cover	1	0
2.	Keep inhaler upright	1	0
3.	Turn the ring under the device anticlockwise and turn it back until click sound	1	0
4.	Keep head upright	1	0
5.	Exhale to residual volume	1	0
6.	Mouthpiece between teeth and lips	1	0
7.	Inhale forcefully and deeply	1	0
8.	Hold breath for 10 sec	1	0
9.	Exhale away from mouthpiece	1	0
10.	Replace the cover (wait a minimum of 20–30 sec before second inhalation)	1	0
Total

	Aerolizer	True	False
1.	Remove cover	1	0
2.	Peel back blister and take out capsule	1	0
3.	Place capsule in the chamber in the inhaler	1	0
4.	Press buttons on both sides to pierce capsule	1	0
5.	Keep head upright	1	0
6.	Exhale to residual volume	1	0
7.	Mouthpiece between teeth and lips	1	0
8.	Inhale forcefully and deeply	1	0
9.	Hold breath for 10 sec	1	0
10.	Exhale away from mouthpiece	1	0
Total

	HandiHaler	True	False
1.	Remove mouthpiece cover	1	0
2.	Open the capsule chamber device	1	0
3.	Place capsule into the inhaler	1	0
4.	Press button so that needle pierces both sides of capsule	1	0
5.	Keep head upright	1	0
6.	Exhale to residual volume	1	0
7.	Mouthpiece between teeth and lips	1	0
8.	Inhale forcefully and deeply	1	0
9.	Hold breath for 10 sec	1	0
10.	Exhale away from mouthpiece	1	0
Total

Ethics committee approval

The decision of ethics committee approval (09/27) was obtained by the Ethics Committee of the Faculty of Medicine, Erciyes University. Also, verbal approval and an informed consent from the participants were obtained by explaining the purpose of the study.

Data analysis

Data were analyzed with SPSS 17.0 and SigmaStat 3.5 statistical package programs. Cronbach alpha coefficients were used for determining reliability of scales.

Power analysis was used to determine the adequacy of the number of participants in both groups for comparing the scales. Normality of data was checked by the Shapiro Wilk test. Dependent-samples t and Wilcoxon tests were used for normally and non-normally distributed variables, respectively. The χ² test was used to compare categorical variables. p<0.05 was accepted as statistically significant.

Results

In the intervention group, 79.4% were male, 38.2% were 59 years old and younger, 55.9% graduated from elementary school, 91.2% were married, and 64.7% had moderate income status; in the control group, 85.7% were male, 45.7% were the ages of 60–69 years, 54.3% graduated from elementary school, 94.3% were married, and 65.7% had moderate income status. Descriptive characteristics were similar between the two groups (p>0.05).

Time of diagnosis, COPD stage, smoking status, characteristics about inhaler usage, and inhaler training are shown in Table 3. Baseline characteristic of the disease and smoking status were similar between groups (p>0.05). The two groups were also similar in terms of inhaler usage duration, number of inhalers, and receiving of inhaler training (p>0.05). Half of the intervention group patients had been using inhaler for 2–4 years, 64.7% were using two inhalers, 76.5% had been given inhaler training before, and of them 81.5% were educated by the physician.

Table 3.

Some Baseline Characteristics of the Patients

	Intervention group (n=34)		Control group (n=35)
	n	%	n	%	Statistical test
Duration of diagnosis
1 year and less	4	11.8	7	20.0	χ²=0873
2–5 years	15	44.1	14	40.0	p=0.689
6 years and more	15	44.1	14	40.0
COPD stage
Moderate	23	67.6	24	68.6	χ²=0.007
Severe	11	32.4	11	31.4	p=1.000
Smoking status
Gave up smoking	18	52.9	18	51.4	χ²=0.038
Never smoked	9	26.5	10	28.6	p=1.000
Still smoking	7	20.6	7	20.0
Duration of smoking ( n =50)
20 years and less	4	16.0	3	12.0	χ²=0.234
21–30 years	9	36.0	9	36.0	p=1.000
31–40 years	5	20.0	6	24.0
41 years and more	7	28.0	7	28.0
Number of cigarettes per day ( n =50)
1 package and less	13	50.0	15	62.5	χ²=1.287
2 packages	10	38.4	8	33.3	p=0.635
3 packages and more	3	11.6	1	4.2
Duration of inhaler usage
1 year and less	12	35.3	11	31.4	χ²=0.362
2–4 years	17	50.0	17	48.6	p=0.899
5 years and more	5	14.7	7	20.0
Number of inhalers
1	8	23.5	7	20.0	χ²=2.195
2	22	64.7	19	54.3	p=0.396
3	4	11.8	9	25.7
Inhaler type
MDI	17	70.8	7	20.2	χ²=4.324
Turbuhaler	4	50.0	4	50.0	p=0.374
Diskus	11	57.8	8	42.2
Aerolizer	19	45.2	23	54.8
HandiHaler	21	51.2	20	48.8
Inhaler training
Got	26	76.5	29	82.9	χ²=0.435
Did not get	8	23.5	6	17.1	p=0.561

Mean inhaler scores in the first interview of patients in both groups were 6.8 for Diskus, 6.7 for Aerolizer, 6.5 for HandiHaler, 6.5 for Turbuhaler, and 5.1 for MDI, which showed that intervention group patients had difficulty mostly in using the MDI.

All of the control patients were found to use the inhaler incorrectly in the follow-up, whereas 82.4% of the educated patients used the inhaler in correct steps after the training (x²=51.496, p<0.001).

Table 4 shows inhaler scores in the first and second interviews; the median inhaler score of intervention group patients in the first interview increased from 5.0 to 10.0 for MDI, and from 7.0 to 10.0 for Turbuhaler, Diskus, Aerolizer, and HandiHaler. The inhaler scores were found to increase in the second interview in the intervention group for all types of inhalers, and the increases were statistically significant for all inhalers except the Turbuhaler (p<0.05).

Table 4.

Inhaler Scores of Study Groups According to Inhaler Types

	Intervention group				Control group
	1st Interview	Follow-up			1st Interview	Follow-up
Inhaler type	Median (%25p. –%75p.)	Median (%25p. –%75p.)	p	Inhaler type	Median (%25p. – %75p.)	Median (%25p. – %75p.)	p
MDI(n=17)	5.0 (4.0–6.0)	10.0 ( 9.0–10.0)	Z=2.375p=0.018	MDI(n=7)	5.0 ( 4.0–6.0)	4.0 (4.0– 5.5)	Z=1.469p=0.142
Turbuhaler(n=4)	7.0 (5.5–8.5)	10.0 (10.0–10.0)	Z=1.841p=0.066	Turbuhaler(n=4)	6.5 (4.5–7.0)	5.5 (5.0– 6.0)	Z=0.577p=0.564
Diskus(n=11)	7.0 (6.0– 8.0)	10.0 (10.0–10.0)	Z=2.956p=0.003	Diskus(n=8)	6.5 (5.2–7.7)	6.0 (5.2–7.0)	Z=0.736p=0.461
Aerolizer(n=19)	7.0 (6.0–8.0)	10.0 (10.0–10.0)	Z=3.858p<0.001	Aerolizer(n=23)	7.0 (6.0–7.0)	7.0 (6.0–7.0)	Z=1.311p=0.190
HandiHaler(n=21)	7.0 (6.0–7.5)	10.0 ( 9.0–10.0)	Z=4.045p<0.001	HandiHaler(n=20)	6.0 ( 6.0–7.0)	6.0 (6.0–7.0)	Z=0.816p=0.414

p.=percentile

Among the intervention group patients, 14.3% of the MDI users applied the “exhalation” step correctly, but all of the patients were incorrect while “squeezing inhaler with slowly starting to breathe” and “holding breath for 10 seconds.” In the second interview, 85.7% were correct while “squeezing inhaler with slowly starting to breathe” and corrected their mistakes in the other steps (100%). Of the control subjects, 29.4% and 11.8% were correct in “exhalation” and “breath emptying,” respectively, whereas 5.9% applied the steps of “squeezing inhaler with slowly starting to breathe” and “holding breath for 10 seconds” correctly.

However, they applied the steps of “exhalation” and “squeezing inhaler with slowly starting to breathe” wrongly besides 5.9% who were correct while “emptying breath” (p>0.05).

Patients who were using the dry powder inhaler (DPI) were mostly wrong in the steps of “exhalation,” “taking a deep and strong breath,” “holding breath for 10 seconds,” and “emptying breath completely.”

Intervention group patients were found to correct those mistakes in follow-up, but controls did not, and even the ratio of making mistakes was found to increase in controls.

After the second interview, 45.7% of control patients had an attack, 20.0% applied to emergency service, and 11.4% were hospitalized, whereas 5.9% of the intervention group had an attack, 2.9% applied to emergency service, and 2.9% were hospitalized, which showed that living attack, emergency application, and hospitalization were observed more in the control group than in the intervention group, with “attack” being significantly different (p<0.001) (Table 5).

Table 5.

Attack, Emergency Application, and Hospitalization of Study Groups in the Follow-up

	Intervention group (n=34)		Control group (n=35)
	n	%	n	%	Test
Attack
Yes	2	5.9	16	45.7	χ²=14.191
No	32	94.1	19	54.3	p<0.001
Emergency application
Yes	1	2.9	7	20.0	χ²=4.896
No	33	97.1	28	80.0	p=0.055
Hospitalization
Yes	1	2.9	4	11.4	χ²=1.848
No	33	97.1	31	88.6	p=0.356

The mean score of quality of life for the intervention group was found to decrease from 43.5±14.9 to 30.5±14.9 for the subdimension of “effect,” from 51.2±21.8 to 25.7±15.8 for “symptom,” from 66.9±19.4 to 57.5±19.5 for “activity,” and totally from 51.9±15.6 to 37.9±14.4, which meant that quality of life for all subdimensions and overall had increased in the follow-up (p<0.001). A statistically significant difference in the score of overall quality of life and its subdimensions in the control group was not determined (p>0.05) (Table 6).

Table 6.

Quality Of Life and Dyspnea Score of Study Groups

	Intervention group (n=34)			Control group (n=35)
	1st Interview	Follow-up		1st Interview	Follow-up
Variables	\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\bar{X}$$ \end{document} ±SS Median (%25p. – %75p.)	\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\bar{X}$$ \end{document} ±SS Median (%25p. – %75p.)	p	\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\bar{X}$$ \end{document} ±SS Median (%25p. – %75p.)	\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} $$\bar{X}$$ \end{document} ±SS Median (%25p. – %75p.)	p
Quality of life
Impact	43.5±14.941.1 (34.5–56.9)	30.5±14.930.1 (17.9–41.2)	t=–6.307p<0.001	49.6±18.651.6 (40.2–69.6)	49.2±17.051.4 (36.4–59.6)	t=−0.164p=0.871
Symptom	51.2±21.848.8 (35.3–68.1)	25.7±15.821.9 (11.8–37.8)	t=–8.266p<0.001	53.3±21.151.5 (40.2–69.6)	50.2±21.950.7 (33.0–69.0)	t=–0.670p=0.507
Activity	66.9±19.466.7 (54.3–82.0)	57.5±19.530.1 (17.9–41.2)	Z=3.198p=0.001	71.7±18.667.7 (54.5–87.4)	71.9±17.774.3 (60.2–86.5)	Z=0.821p=0.412
Total	51.9±15.651.2 (41.8–61.7)	37.9±14.434.9 (25.5–52.8)	t=8.113p<0.001	56.9±16.158.7 (44.8–71.0)	56.2±15.857.6 (44.7–68.0)	t=0.316p=0.754
Dispne Scales
Borg	2.5±1.32.0 (2.0–3.0)	2.3±1.32.0 (1.0–3.0)	Z=–1.02p=0.307	2.6±1.33.0(2.0–3.0)	3.3±0.83.0 (3.0–4.0)	Z=–2.65p=0.008
MRC	3.1±0.83.0 (2.0–4.0)	2.7±0.92.0 (2.0–4.0)	Z=–2.27p=0.023	3.4±0.94.0 (3.0–4.0)	3.3±0.93.0 (3.0–4.0)	Z=–0.22p=0.819

p.=percentile

The mean score of the Borg dyspnea scale of controls was 2.6±1.3 in the first interview and increased to 3.3±0.8 in the second, which showed that dyspnea increased. This difference was statistically significant (p<0.05). The median MRC score in the first interview of intervention group was 3.0 and decreased to 2.0 in the second one, which demonstrated that dyspnea conditions significantly decreased (p<0.05) (Table 6).

Discussion

Inhaler medicines in COPD treatment provide an optimal therapy by being fast and highly efficient and causing low side effects while directly reaching the target organ, the lungs.⁽³⁾ The success of inhaler therapy is based on the correct use of the inhaler device.

The application of proper technique by patients is possible with planned and regularly repeated patient education. In the present study, the majority of patients in the intervention group (82.4%) used the inhaler correctly in the follow-up, whereas all of the controls did not (p<0.001).

Study results have demonstrated that inhaler training had an impact on proper inhaler use.^(25,26) Inhaler-using patients in a similar study were found to correct all of the mistakes related to inhaler usage after they were given training.⁽²⁷⁾ Luk et al.⁽¹²⁾ determined that the inhaler score of COPD patients using MDI increased from 61±28 to 89±11 (per 100) after the training.

The GOLD guideline emphasizes the importance of evaluating the inhaler-using technique of patients who are inadequate and training them along with regularly controlling their technique.⁽²⁾ However, relevant studies have shown that the efficacy of education diminished over time and suggested that frequent monitoring and repeated training would provide continuity of using the inhaler with proper technique.^(16,24,28)

Most of the participants in both groups had been educated on inhaler use, mainly by physicians. But when the content of that training was questioned, the patients mentioned that the training had not been planned training but included only short lectures.

Although receiving training on inhaler use was high among patients with COPD, the reason why they had not been using the inhaler correctly might be due to unscheduled patient education and usage of only verbal training.

Although most of the patients (78.0%) in Valero and colleagues' study had been given training on inhaler use, only 31.6% were correctly applying the medicine.⁽²⁹⁾

Song et al.⁽³⁰⁾ have found that 40.9% of patients had been using an inhaler for many years without being given any education.

In the present study, 17.6% of the intervention group used an incorrect technique 3 months after the training, which demonstrated that patients forgot the correct technique, thus presenting the necessity of repeating training constantly.

Patients who use MDI were found to make more mistakes compared with DPI users in several studies.^(31–33)

The authors of the present study have focused on similar findings that showed that mostly MDI users applied techniques inaccurately. The mean score for MDI of the groups was 5.1±1.2 (per 10) before the study. Only 9.0% of the MDI-using patients were properly applying the inhaler in a study of Plaza et al.⁽³⁴⁾ The mean score for MDI was 4.3 (per 10) in Hacıevliyagil and colleagues' study, whereas Mirici et al. have found 4.4.^(8,35)

The MDI-using patients with COPD participating in the present study mostly made mistakes in “exhalation prior to inhalation,” “squeezing inhaler with slowly starting to breathe,” “holding breath for 10 seconds,” and “emptying breath slowly.” In a similar study, mistakes made most often in MDI use were “not being able to hold breath after inhalation,” “not waiting for 30 seconds between two inhalations,” and “lack of coordination during inspiration.”⁽²⁹⁾ Bosnic-Anticevich et al.⁽²⁸⁾ have stated that MDI users were most frequently incorrect while “exhaling prior to inhalation,” “inhaling slowly and deeply,” and “holding breath for 10 seconds.”

Study results have demonstrated that DPI-using patients were making fewer mistakes than DPI users.^(36–38)

DPI-using patients in the present study had mean inhaler scores of 6.8±1.2, 6.7±0.8, 6.5±0.92, and 6.5±1.5 for Diskus, Aerolizer, HandiHaler, and Turbuhaler, respectively. Based on these findings, patients with COPD were incorrect mostly with Turbuhalers and HandiHalers and minimally with Diskus among DPIs, which was similar compared with the study results of Khassawneh et al.,⁽³⁹⁾ who have demonstrated that the fewest mistakes were made with Diskus followed by Aerolizer and Turbuhaler. Incorrect applications were exhibited by 9.1% of Aerolizer users, by 26.7% of Diskus users, by 34% of Turbuhaler users, and by 53.1% of HandiHaler users in the study of Wieshammer and Dreyhaupt.⁽⁴⁰⁾

In the present study, DPI-using patients with COPD were incorrect mostly in “exhalation prior to inhalation,” “holding breath for 10 seconds,” and “emptying breath slowly.”

Skipping the stage of “exhalation prior to inhalation” by patients leads to being bad at inhaling strongly and deeply, which cannot provide an adequate reach of the medicine to the lungs.

Molimard et al.⁽³⁸⁾ have focused on the most common mistakes that were made by 28.9% and 28.3% of the patients (“exhalation prior to inhalation” and “holding breath after inhalation,” respectively). Some other studies have put emphasis on similar findings.^(13,35)

Attacks are important reasons affecting health status and quality of life and increasing morbidity and mortality in patients with COPD.⁽⁴¹⁾

Attacks and deficient symptom control result from mistakes in inhaler use.⁽¹⁷⁾ Living attack, emergency application, and hospitalization during the 3 months after the training in the educated patients were seen less compared with controls, whereas there was a statistically significant difference in attacks (p<0.05) (Table 5).

Wrong inhaler use caused inadequate disease control in patients with asthma, and inhaler training resulted in a decrement in the severity of disease.^(5,14)

According to the dyspnea scales of two groups in the current study, the MRC dyspnea scale of educated patients significantly decreased after the training and the score of the Borg scale of controls increased significantly in the follow-up, which showed an increment in the severity of dyspnea condition for controls (Table 6). In another study, there has been found less dyspnea frequency after inhaler-use training.⁽⁴²⁾

COPD is one of the leading conditions causing mortality and morbidity among chronic lung diseases and affecting quality of life of patients with COPD.^(22,43) According to the follow-up mean scores of quality of life of patients in both groups, the quality of life of the intervention group was found to increase in all dimensions (activity, effect, symptom, and overall), whereas no change was determined in controls (Table 6).

Hesselink et al.⁽⁴⁾ have also showed that incorrect inhaler technique resulted in low quality of life.

In Basheti and colleagues' study with asthma patients,⁽⁵⁾ the inhaler training significantly improved the quality of life of educated patients more than controls. Güner and Atak⁽⁴⁴⁾ have determined that comprehensive health education given to patients with COPD improved quality of life.

Consequently, in the present study, the planned inhaler training given to individuals with COPD was found to promote correct inhaler use significantly, to reduce frequency of attacks and dyspnea condition, but increased quality of life.

Nurses are the primary responsible health-care professionals in patient education. Therefore, it is crucial to control the inhaler-using status of both outpatients and inpatients by inhaler checklist, to give planned training to those using inhalers incorrectly, and to repeat the training at regular intervals. Conducting longer-term studies in which more frequent follow-ups are done in wider populations may be beneficial to support the findings of our results.

Limitations

The study may be conducted with a wider sample of patients or to a less extend of inhaler types. Studies with such design may be conducted in the future.

Footnotes

Acknowledgments

This study was funded by the scientific research projects, coordination unit, University of Erciyes. We are also indebted to the pulmonary function technicians and clerical staff of the Department of Chest. Furthermore, we would like to thank H. Büyükoğlan for his valuable comments and support. All authors took part in all stages of the study.

Author Disclosure Statement

The authors declare that no conflicts of interest exist.

References

Celli

, MacNee

. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J, 2004; 23:932–946.

Global Strategy for Diagnosis, Management, Prevention of COPD. 2008 September 2008. http://www.goldcopd.com. 2012 December 31.

Wright

, Broclebank

. Inhaler devices for the treatment of asthma and chronic obstructive airway disease (COPD) Qual Saf Health Care, 2002; 11:376–382.

Hesselink

, Penninx

BWJH

, Wijnhoven

HAH

, Kriegsman

DMW

, Eijk

JTM

. Determinants of an incorrect inhalation technique in patients with asthma or COPD. Scand J Prim Health Care, 2001; 19:255–260.

Basheti

, Armour

, Anticevich

SZB

, Reddel

. Evaluation of a novel education strategy, including inhaler-based reminder labels to improve asthma inhaler technique. Patient Educ Couns, 2008; 72:26–33.

Fink

, Rubin

. Problems with inhaler use: a call for improved clinician and patient education. Respir Care, 2005; 50:1360–1373.

Rokosky

. Teaching correct use of inhaled medications. Home Healthc Nurse, 2005; 23:766–774.

Hacıevliyagil

, Arıkan

, Günen

. Inhaler technique of patientsHacettepe UniversityJournal of the Faculty of Pharmacy, 2005; 25:51–60.

Shrestra

, Parupia

MFH

, Andrews

, Kim

, Martin

, Park

, Gee

. Metered-dose inhaler technique of patients in an urban ED: prevalence of incorrect technique and attempt at education. Am J Emerg Med, 1996; 14:380–384.

10.

Newman

, Busse

. Evolution of dry powder inhaler design formulation and performance. Respir Med, 2002; 96:293–304.

11.

Coackley

. Helping patients to master correct inhaler techniques: nursing role. Br J Nurs, 2010; 7:424–430.

12.

Luk

, Chan

, Lam

, Lau

, Chiu

, Fung

, Pang

. Teaching chronic obstructive airway disease patients using a metered-dose inhaler. Chin Med J, 2006; 119:1669–1672.

13.

Lavorini

, Magnan

, Dubus

, Voshaar

, Corbetta

, Broeders

, Dekhuijzen

, Sanchis

, Viejo

, Barnes

, Corrigan

, Levy

, Crompton

. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med, 2008; 102:593–604.

14.

Giraud

, Roche

. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J, 2002; 19:246–251.

15.

Abley

. Teaching elderly patients how to use inhalers. A study to evaluate an education programme on inhaler technique for elderly patients. J Adv Nurs, 1997; 25:699–708.

16.

Takemura

, Kobayashi

, Kimura

, Mitsui

, Masui

, Koyama

, Itotani

, Ishitoko

, Suzuki

, Aihara

, Matsumoto

, Oguma

, Ueda

, Kagioka

, Fukui

. Repeated training on inhalation technique improves adherence to the therapeutic regimen in asthma. J Asthma, 2010; 47:202–208.

17.

Barnett

. Improving drug concordance in patients with COPD. Nurse Prescribing, 2007; 5:199–204.

18.

Özvarış

ŞB

. Health Education and Health Promotion. Hacettepe Public Health Foundation: Ankara, Turkey, 9–10. 2001.

19.

Borg

. Psychophysical basis of perceived exertion. Med Sci Sports Exerc, 1982; 14:377–381.

20.

Fletcher

, Elmes

, Wood

. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. Br Med J, 1959; 2:257–266.

21.

Jones

, Quirk

, Baveystock

. The St George's respiratory questionnaire. Respir Med, 1998; 5:25–37.

22.

Özkan

, Durna

, Demir

, Gemicioğlu

. Assessment of the functional performance and quality of life in patients with COPD and asthma. Respiration, 2007; 9:158–166.

23.

Togger

, Brenner

. Metered dose inhalers. Am J Nurs, 2001; 101:26–32.

24.

Broeders

, Sanchis

, Levy

, Crompton

, Dekhuijzen

. ADMIT Working Group. The ADMIT series—issues in inhalation therapy 2. Improving technique and clinical effectiveness. Prim Care Respir J, 2009; 18:76–82.

25.

Van der Palen

, Klein

, Kerkhoff

, Van Herwaarden

, Seydel

. Evaluation of the long-term effectiveness of three training modes for inhaling medicines. Patient Educ Couns, 1997; 32:S87–S95.

26.

Hesselink

, Penninx

BWJH

, van der Windt

DAWM

, van Duin

, de Vries

, Twisk

JWR

, Bouter

, Van Eijk

JTM

. Effectiveness of an education programme by a general practice assistant for asthma and COPD patients: results from a randomised controlled trial. Patient Educ Couns, 2004; 55:121–128.

27.

Abadoğlu

, Yalazkısa

, Ülger

, Paşaoğlu

, Mısırlıgil

. The role of education by a well-trained nurse on correct utilization of inhalation devices. J Turkish Med Sci J Allergy Asthma, 2003; 5:11–15.

28.

Bosnic-Anticevich

, Sinha

, So

, Reddel

. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma, 2010; 47:251–256.

29.

Carrion Valero

, Maya Martinez

, Fontana Sanchis

, Diaz Lopez

, Marin Pardo

. Inhalation technique of patients with chronic respiratory diseases. Arch Bronconeumol, 2000; 36:236–240.

30.

Song

, Mullon

, Regan

, Roth

. Training of hospitalized patients by respiratory therapists on metered-dose inhaler use leads to decrease in patient errors. Respir Care, 2005; 50:1040–1045.

31.

Dahl

, Backer

, Ollgaard

, Gerken

, Kesten

. Assessment of patient performance of the HandiHaler compared with the metered dose inhaler four weeks after training. Respir Med, 2003; 97:1126–1133.

32.

Nimmo

CJR

, Chen

DNM

, Martinusen

, Ustad

, Ostrow

. Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices. Ann Pharmacother, 1993; 27:922–927.

33.

Souza

MLM

, Meneghini

, Ferraz

, Vianna

, Borges

. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Brasil Pneumol, 2009; 35:824–831.

34.

Plaza

, Giner

, Gomez

, Casan

, Sanchis

. Health workers' knowledge and skills regarding the use of the Turbuhaler inhaler. Arch Bronconeumol, 1997; 33:113–117.

35.

Mirici

, Meral

, Akgün

, Sağlam

, İnandı

. Factors effecting patients' compliance to inhalation techniques. Respir Dis, 2001; 12:13–21.

36.

Van der Palen

, Klein

, Kerkhoff

AHM

, Van Herwaarden

CLA

. Evaluation of the effectiveness of four different inhalers in patients with chronic obstructive pulmonary disease. Thorax, 1995; 50:1183–1187.

37.

Rootmensen

, Van Keimpema

ARJ

, Jansen

, Haan

. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv, 2010; 23:1–6.

38.

Molimard

, Raherison

, Lignot

, Depont

, Abouelfath

, Moore

. Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med, 2003; 16:249–254.

39.

Khassawneh

, Al-Ali

, Alzoubi

. Handling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalers. Respir Care, 2008; 53:324–328.

40.

Wieshammer

, Dreyhaupt

. Dry powder inhalers: which factors determine the frequency of handling errors? Respiration, 2008; 75:18–25.

41.

Seemungal

, Donaldson

, Paul

, Bestall

, Jeffries

, Jadwiga

, Wedzicha

. Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 1998; 157:1418–1422.

42.

Verver

, Poelman

, Bogels

, Chisholm

, Dekker

. Effects of training by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study. Fam Pract, 1996; 13:35–40.

43.

Gürgün

, Erdinç

. Evaluation of Quality of Life in Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease from Definition to Treatment. Toraks Books: Bursa, Turkey, 374–382. 2008.

44.

Güner

, Atak

. Evaluation of effects of health education on life quality of patients with chronic obstructive pulmonary diseaseAnkara UniversityJournal of the Medical Faculty, 2001; 54:321–332.